At Umpqua Health, we're more than just a healthcare organization; we're a community-driven Coordinated Care Organization (CCO) committed to improving the health and well-being of individuals and families throughout our region. Our comprehensive services include primary care, specialty care, behavioral health services, and care coordination to ensure our members receive holistic, integrated healthcare. Our collaborative approach fosters a supportive environment where every team member plays a vital role in our mission to provide accessible, high-quality healthcare services. From preventative care to managing chronic conditions, we're dedicated to empowering healthier lives and building a stronger, healthier community together.
Umpqua Health strongly encourages applications from candidates of color as well as veterans, aiming to foster a work environment that is linguistically and culturally diverse and inclusive. Please note that at this time, Umpqua Health does not offer visa sponsorship.
The Appeals and Grievances Specialist plays a critical role in ensuring that health plan members receive appropriate and timely resolutions to appeals and grievances in compliance with regulatory requirements. The Specialist will review, investigate, and resolve member complaints, appeals, and grievances related to their healthcare services, coverage, and benefits. This role requires strong communication skills, attention to detail, and the ability to navigate complex regulations while delivering excellent customer service.
Why Choose Umpqua Health?
Impactful Work: Make a difference in our community by helping members navigate their healthcare needs.
Supportive Environment: Join a collaborative team committed to your success and professional growth.
Comprehensive Benefits: Enjoy competitive pay, medical/dental/vision insurance, and opportunities for advancement.
Innovative Culture: Contribute to ongoing process improvements and technological advancements in healthcare service delivery.
\n- Review and process member appeals related to healthcare services, claims, and coverage determinations.
- Conduct thorough investigations of member appeals by gathering and analyzing relevant documents, medical records, and plan policies.
- Collaborate with internal departments such as claims, medical management, and legal to ensure a comprehensive review.
- Ensure timely resolution in accordance with health plan policies and regulatory standards, including Medicare, Medicaid, and commercial insurance requirements.
- Investigate and resolve member grievances regarding service delivery, access to care, and interactions with healthcare providers.
- Maintain detailed case documentation, including complaint summaries, actions taken, and final resolutions.
- Prepare and deliver member communications explaining outcomes and any follow-up steps.
- Ensure all appeals and grievances are handled in compliance with federal and state regulations, including CMS (Centers for Medicare & Medicaid Services) guidelines and Department of Insurance requirements.
- Monitor regulatory changes and ensure processes are updated as needed to stay in compliance.
- Prepare reports on appeals and grievances activity, trends, and outcomes for internal stakeholders and regulatory agencies.
- Serve as a point of contact for members throughout the appeals and grievances process, providing clear and compassionate communication.
- Educate members on their rights and health plan processes regarding appeals and grievances.
- Provide support to members experiencing dissatisfaction with health plan services or coverage.
- Perform other duties and support deliverables as assigned by the organization to help drive our Vision, fulfill our Mission, and abide by our Organization’s Values.
- Bachelor’s degree in healthcare administration, business, public health, or a related field preferred.
- Equivalent experience in healthcare or managed care environments may be considered
- 2+ years of experience in healthcare appeals and grievances, claims, or related member services roles.
- Familiarity with health plan operations, regulatory compliance, and the appeals/grievances process for Medicare, Medicaid, and commercial insurance plans.
- Strong knowledge of healthcare regulations (CMS, Medicaid, etc.) and managed care policies.
- Excellent written and verbal communication skills.
- Exceptional organizational and time management skills with the ability to handle multiple cases simultaneously.
- Strong analytical and problem-solving abilities.
- Proficiency in Microsoft Office and healthcare management systems (e.g., claims processing software, CRM).
Umpqua Health is an equal opportunity employer that embraces individuals from all backgrounds. We prohibit discrimination and harassment of any kind, ensuring that all employment decisions are based on qualifications, merit, and the needs of the business. Our dedication to fairness and equality extends to all aspects of employment, including hiring, training, promotion, and compensation, without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other protected category under federal, state, or local law.